Hey Guys,

I just wanted to bring this article to everyone’s attention. For my presentation in a few weeks I will be discussing alcohol and substance use during pregnancy, but I just wanted to share this since it was published a little over a week ago in a magazine (Cosmopolitan) that caters to women of reproductive age. The article discusses how the author, Michelle Ruiz, would casually drink a couple glasses of wine or beer a week during her pregnancy and even suggests that up to 8 glasses is acceptable. Drinking during pregnancy has been an increasing topic as there have been a few new pregnancy books published that say drinking is okay. She sites one danish study and references many of her doctor and nurse friends that say casually drinking a little everyweek is okay. As you read the article it becomes clear that the use of alcohol during pregnancy is rooted in culture. She talks about how generations before drank and smoked during their pregnancy and “here we all are”. Drinking during pregnancy is a growing topic as more and more people are testing this “dirty little secret” that is happening among “college-educated, employed women in their late 30s” according to Michelle Ruiz.

http://www.cosmopolitan.com/sex-love/news/a32292/why-i-drank-while-i-was-pregnant/

While reading The State of The Worlds Midwifery report there was mentions of the progress improved maternal health has had on countries. With better maternal health, in part due to midwives, economies have improved as well as other MDG’s. The report was mentioning some ways that midwives could continue to foster progress in nations that the MDG’s are aimed toward. One method for helping improvement mentioned was midwives having political standing. I think that would be a wonderful idea for there to be a group of people focused solely on policy and legislation for midwives and mothers. I think this group could focus on getting training to regions that practice midwifery in an unskilled manner, such as Guatemala. Providing instruments and education to places that need more skilled midwives or even education to places like that US that midwifery is still around and only beneficial to women and birth outcomes. That stated, I realize midwives have been around for quite some time and so has the government. I am not very savvy on how organizations like the one they have mentioned in the midwife report would start or carry on. So, I am wondering what has stopped this from not already being an established area of policy and what barriers would a coalition like this face? It is clear to see that midwives are beneficial to communities in more ways than just attending births. Also, on this report itself I think it is a wonderful publication and very important to show the strides the practice of midwifery makes in the world of health. I just wonder whom this publication goes out to, and are the parties that need to see it being made aware of the benefits that midwifery provides to a nation.

The word “midwife” has many different connotations depending on perspective. Some see  midwives as healers and helpers. Some see them as skilled and wise. Some see them as agents of women’s empowerment. However, because of the history of midwifery and its relationship with class-perception, many see midwives as uneducated, old, primitive women. Before hospital birth was normalized, “granny” or “traditional” midwives were largely responsible for attending births, which typically took place in the home. This was the case for women of all classes in many different countries, developed and less-developed. As hospital birth became more common in the late nineteenth century, middle and upper class women began delivering in hospitals, but poorer women continued to deliver at home with a midwife. This (along with campaigns by hospitals involving ads like the one at this link: http://tinyurl.com/filthymidwife) led to a stigma against midwives that continues to distort society’s perception of midwives in developed nations, who were most influenced by the hospitalization of birth.

In reality, although contemporary midwives do have similar practices and philosophies to traditional midwives, the work of midwives today is largely influenced by the medicalization of birth. Most midwives in developed nations are nurse-midwives, who have had training in a clinical setting (State of the World’s Midwifery Report). Nurse-midwives practicing in the United States and in more remote areas of the world incorporate the philosophy of traditional midwifery with common hospital practices; for example, nurse-midwives attending home births are often equipped with pain medication, pitocin, or other medical supplies. They also often partner with hospitals in case of a need for emergency hospital-transfer. Interestingly, modern midwifery care also mimics the trend of hospital normalization by serving primarily middle to upper-class, white women. This article discusses the midwife-preference among white, affluent women and why it matters: http://nursingclio.org/2012/06/28/designing-women-midwives-class-and-choice/.

A key aspect of the midwifery model of care has stayed the same throughout generations: midwife-attended births result in less prevalence of medical interventions. A midwife’s philosophy is that a woman has the power to labor and deliver in most cases without medical interventions, such as C-sections. Midwives teach their patients to be confident in their ability to labor and are unlikely to recommend a C-section unless it is medically necessary. The World Health Organization recommends that a nation’s C-section rate be 10% or lower. However, a 2010 WHO study determined that only 54 countries out of the 137 countries sampled have C-section rates below 10%. The same study determined that out of 9.38 million C-sections performed in 2008, 6.20 million were medically unnecessary. This resulted in an excess of over $2 billion spent, and thus WHO identified unnecessary C-sections as a barrier to universal coverage of care (http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf). It is no coincidence that WHO recommends midwives as a way to improve global maternal care. Midwives reduce the number of unnecessary C-sections, preventing surgical complications and saving money.

This week’s reading on Labor, Privatization and Class opened my eyes to the differences socially and culturally between America and various countries. Notably, there exists a high importance of intra-household hierarchies and the division of labor between family members in countries such as India, while in America there exists a more relaxed and malleable description of family life. The case study in Calcutta, India shows that domestic and kin relationships affect a pregnant woman’s access, use and knowledge of the healthcare system. The common trend found among pregnant women in India show a high percentage giving birth in a private institution as well as a high percentage of women having elective C-sections. This was shown to be more prevalent in middle- and high-class families, as well as in urban verses rural areas. I found it interesting that more women choose private birth centers over hospitals, given our recent class discussion of birthplace ranging from hospital, birth center, and home birth. Notably, the chapter bases these decisions on Indian women’s lack of trust and credibility of hospitals, whereas birth centers give the comfort and personal interest in wellbeing that the women are looking for. In addition, modern technology is seen as a blessing, and a way to enable a healthy infant born at a suitable time for the parents. It is shown as a prestigious technique, allowing women to avoid pain, shame and the cultural belief in pollution that follows a natural vaginal birth. In 2012, research shows that in Indian private institutions women are 3 to 10 times more likely to have an elective C-section than in hospital settings. In comparison to the US, more elective C-sections occur at hospitals than private institutions. The difference in these statistics may be due to differences in the wishes of pregnant women, who may prefer C-sections more in India than in the US. However, I believe this difference may be based on the characteristics of women who choose to give birth in each setting, while in the US most women attend a hospital birth women in India prefer a private institution and thus have different expectations of care.

Sources:

http://timesofindia.indiatimes.com/india/Private-hospitals-fuel-C-section-epidemic/articleshow/15331864.cms

We previously compared the United States and rural Ethiopia. Originally I was going to post this as a “Birth in Two Nations” blog but I found that Ila’s story was related to more than one country and circumstance. I was reminded of the story of Monique’s friend in Monique and the Mango Rains while reading the first block quote from Ila. Firstly, she worked all the way up until her pregnancy. This was just like the case in Mali, however, Ila found rest for a month after giving birth whereas the women in Mali were not so lucky. Though it was urged that they take a break, the duties of life usually did not allow for this. At first I chucked this up to the fact that in South Calcutta Ila had her in-laws to help but in Mali the woman may live with her in-laws but she was expected to serve them as well as opposed to being served by them.

Secondly, I drew a parallel to American births when Ila made mention of a nurse doing all the check ups but a doctor delivering the baby. We discussed this in class while talking about the pros and cons of hospital birth. Though her birth took place in a nursing home (which I took to be similar to a birthing center) it still seemed to have the level of intimacy of a hospital which is low. More autonomy is removed in not being told the sex of the child before birth even if you would like to know (though this is probably in the best interest of the child as girls may have been aborted).

Lastly, I drew a relation to Adaora’s presentation. Indian has several religions and Ila’s wasn’t stated but I wonder what role religion had in her birth process. As Adaora stated for the Hausa of Northern Nigeria, the Muslim religion had an effect on what medical care a woman in labor could receive. For Ila it did not seem to matter the gender of the health professionals but the husband nor his parents were allowed to be present. However, her male relative was the one who brought her to the nursing home (which would have also been the case for the Hausa). I found it quite interesting how this story seemed to have bits and pieces of the different cultures we had discussed, a perfect example of the crossroads developing India finds itself, between a grasping onto of the traditional and a deserve for new Western ways of doing things.

The reading about pregnancy and birth in Rajasthan from “Reproductive Agency, Medicine and the State” gave a new perspective about pregnancy and the relationship a baby has with its family, in particular the mother. While many of our readings have spoken to how in many societies males are central to the decision making, I found it very interesting how in this culture they not only decided when and what medical attention was sought out, but the relationship between the mother and the baby. Interestingly though babies here are not considered a real person until they are born; in contrast to Western societies where fetuses are often times considered part of the family before the 2nd trimester. However, it is noted that this is because of the high rates of miscarriage and infant mortality in Rajasthan. Here, women are considered to be the “vessels”  for the baby and the men are the “creators” putting more importance on them, furthering the nurturing roles of women in the society. As we have heavily discussed how the head male’s dominance has greatly influenced seeking medical attention in birth there has been little on how a mother see’s the pregnancy and the relationship of seeking medical attention. I have found this perspective of a baby being a “non-person” to be a new insight to this relationship. Mother’s were less inclined to seek medical and prenatal care until they felt the pregnancy would come to term. I feel it is very important to considered cultural aspects like this even though it is still linked to the issue of male dominated society. Education is still the root to improving pregnancy and infant mortality rates. This reading really shows that it is not only important to educate midwives and skilled attendents but educate the mothers. The more they know the more inclined they may be to help/make better decisions about the pregnancy.

        Reading in “Maternal & Child Health” regarding the balance of tradition and midwifery in Guatemala opened my eyes to the reality of giving birth in other nations outside of the United States. While most Americans seek modern technology before, during and after pregnancy and childbirth, this is not the case in many less developed and economically struggling nations. Notably, I was surprised to find that although approximately 71% of births in Guatemala are attended by midwives, a high percentage of these personnel do not meet WHO or UNICEF criteria for skilled birth attendants. When reading the statistic about having midwifes attend the majority of births, I was under the influence that because of this the nation’s infant and maternal mortality rates must be lower than in other nations without the help of birth attendants. However, as the chapter points out Guatemala is among the highest in maternal and infant mortality rates in the Western Hemisphere.  The initiatives taken in the nation helped to train midwives in proper techniques, acknowledging signs of obstructed labor, and help to reduce these rates. One concept I found interesting was the need for support given to midwives, in return for the support they give to pregnant women and their families. For this reason the program Midwives for Midwives was developed, giving them an area for open and honest communication for the work they do and how it affects them. Looking more into this program, I found that between 2007 and 2010 a total of 450 midwives were trained in Guatemala. I find this statistic very hopeful for the future, and the possibility of sustaining the work and dedication numerous health officials have shown the region.

Source: http://www.midwivesformidwives.org/about-us

It was really disheartening to hear about all the issues that rural women and birth attendants in Guatemala face. After reading the second chapter of MCH, I realize that I still have much to learn with how birth looks in different parts of the world. I am aware that not everywhere is going to have hospitals, birthing centers, or even skilled attendants handling the births.  That written, I did not think about a place where so little is known about birth, even those who are seen as the authorities on birth. Most of the examples of birth that take more of a cultural approach that we have seen knew for the most part the basics of pregnancy. For instance, the movie we watched with the black midwives, although the material used might not have been as advanced as a hospital they were extremely skilled and knowledgeable about how pregnancies should go and how to handle emergencies. Same thing goes for Monique in the book we read, even though the setting was rural and she lacked a lot of tools and medication she was skilled in what she was doing when it came to delivering a child. So, with reading this chapter it makes me wonder how the black midwives and Monique got to be so skilled. I am aware the aforementioned characters most likely went through extensive training and assisted on births before becoming so adept- but who taught their teachers? What I am asking is, how does that cycle start? How can you begin a tradition of being aware of things like a fetal heart rate, or what to do during hemorrhage and pass it down? Assuming there are no interventions such as MFM or the like. While pondering this, I came across the idea of an established tradition of birth is what the previous examples had and what the women in Guatemala lacked. I am sure no one came in and had a program of how to teach Monique’s predecessors, as that is not the norm in many parts of the world. In Guatemala, from what I have read, it appears there is really no tradition of birth, like in New Zealand where the community aspect of birth was extremely heightened. I did not get the same sense of the birth of a child being a community experience or really any experience. It seemed that there are traditional midwives who tend to those who are far removed from hospitals but nothing much past that. There are many factors that contribute to this such as illiteracy, no formal training, and the extremely low regard women are held in. I think having such a pronounced low place in society contributes heavily to poor maternal and fetal outcomes. So more community and better appreciation of women could be a solution outside of intervening and just bringing in technology and education.

There are  advantages and disadvantages of giving birth at home, in a birth center, and in a hospital. It can be argued that a hospital provides a safe environment because expert medical help is available should unexpected interventions be needed during the birth process and there are a variety of pain relief options (Nice, 2007). However, women who give birth in a hospital are also more likely to receive some form of medical intervention and many may not be able to relax as well or have as much autonomy because they are in an unfamiliar environment (Wickham, 1999).

Contrasting hospital birth is the idea of giving birth at home. A home birth can be empowering because it allows a woman to labor in the comfort of her own, familiar environment. This may allow a woman to be more relaxed, mobile, and comfortable to do as she pleases throughout labor (Wickham, 1999).  Women are also less likely to have unnecessary interventions if giving birth at home (Oleson, Clausen, 2013). However, there is also the concern that if an emergency arises that there will be a delay in care because the woman must transfer to a hospital.

Lastly, birth centers seem to provide a middle ground between the two extremes of giving birth in a hospital or at home. Birth centers can provide a safe and home-like place for women to give birth and received prenatal and postnatal care, but usually have more resources and may provide quicker transfer to a hospital should an emergency arise (White, 2014).

In the summary of the Chapter 11 case study, “Providing a Safe Space for Birth in Warkworth, New Zealand” the author writes, “…there is no one thing that promotes a positive birth experience for women and their families, but rather an interconnected weaving of many things. Commitment is the common ingredient” (White, 2014).  I believe this is an incredibly profound statement that ultimately sums up what our class agreed upon after our discussion on birth location. All of the previously mentioned advantages and disadvantages of different birth locations only skim the surface of the issues revolving around birth and birth location; as birth is such a unique experience for every woman. This is why I believe that our goal should not be to decide which birth location is best, as this will clearly vary, but to commit to perfecting each of these options so that they are safe and accessible to all women.

Sources:

Nice. 2007. Intrapartum Care – care of healthy women and their babies during childbirth. National Institute of Health and Clinical Excellence. Clinical Guideline 55. London: NICE. www.nice.org.uk

Olsen O, Clausen JA. Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD000352. DOI: 10.1002/14651858.CD000352.pub2.

Symthe, L., Payne, D., Wilson, S., Wynyard S. (2014). Providing a safe space for birth in Warkworth, New Zealand. In White R. (Ed.), Global Case Studies in Maternal and Child Health (pp. 187-208). Seattle: Ascend Learning Company.

WIckham, S. (1999). Homebirth: What are the issues? Retrieved 2014, from Midwifery Today: www.midwiferytoday.com/articles/homebirthissues.asp

I really enjoyed our debate on the very controversial issue of where women should give birth.  I feel that the birthing center has the strongest argument as the ‘best of both worlds’ as far as having aspects of both hospital and home birth, in both developed and undeveloped countries. In birthing centers, there are certified midwifes who not only can manage many complications, but can also provide the support and confidence that women need – thus providing holistic care.  A birthing center can have a ‘home-y’ feel where women can experience childbirth as an emotionally and culturally meaningful life experience like they would at home, rather than in a place associated with sickness.  In addition, giving birth in the hospital costs a lot of money, introduces infants to many pathogens, and results in far more interventions than are needed, which has negative effects on both the mother and infant.  The birthing center can eliminate all of these negatives, while also having a referral plan to transfer women to a hospital if a rare but serious complication should occur. New Zealand has a beautiful model of culturally-appropriate midwifery care in birthing centers that is extremely effective (Smythe, 2014), and I think it would behoove the rest of the world to follow their example. In undeveloped countries—where choice may be an ‘illusion’ as hospitals are far away, understaffed, or lacking equipment—it is all the more essential that more birthing centers are constructed.  In the US, as more birthing centers are being established, the public also needs to be more educated in an unbiased manner on all the different options out there for birth.

Symthe, L., Payne, D., Wilson, S., Wynyard S. (2014). Providing a safe space for birth in
Warkworth, New Zealand. In White R. (Ed.), Global Case Studies in Maternal and Child Health (pp. 187-208). Seattle: Ascend Learning Company.